Fracture fixation technical errors (Proceedings)
Fracture repair results in the creation of a bone-implant composite. Although most of our interventions for fracture repair are successful, at times it seems as though there are an endless number of errors that may prevent the fracture from healing. Fortunately, once the cause of the complication is recognized, the underlying problem can often be corrected and a successful outcome eventually attained.
Failure of a bone-implant composite can occur in one of three ways:
Implant failureImplants rarely fail due to material, manufacturing, or design flaws. Instead the typical cause of implant failure is technical error. Technical error includes poor preoperative assessment/planning, improper implant selection (i.e. the selected implant is inadequate to counteract the forces at the fracture site), and improper application of the implant.
Attachment of the implant to the bone
A set of guiding principles exist for the selection and application of implants. Indeed, one of the major goals of this course is help familiarize the surgeon with these guiding principles. When implants loosen, critical evaluation of the repair often reveals that one or more of these principles was violated. Although there are some underlying common principles, a specific set of guidelines exist for application of pins, wire, plates, screws, and external skeletal fixation.
The bone can fail to heal
In addition to the presence of instability, bone fails to heal when the biologic environment is poor secondary to trauma, or if the biologic environment has been compromised by the method of repair. Examples include open fractures with devascularized tissue secondary to trauma, or fractures with avascular and unstable fragments secondary to iatrogenic trauma. In instances where the biologic environment is insufficient to allow healing, nearly all bone-implant constructs will eventually fail.
In many instances fracture healing can be aided by considering the cause of the injury, the condition of the surrounding soft tissues, the forces acting at the fracture site, and factors inherent to the patient (age, body status, general health) when selecting a repair technique. Techniques to promote fracture healing, such as application of a cancellous bone graft, are often beneficial and are rarely contraindicated.